From the Guidelines
Hemorrhoids should be managed with non-operative treatment as the first line of therapy, focusing on dietary and lifestyle changes, such as increased fiber and water intake, as well as adequate bathroom habits, as recommended by the most recent guidelines 1, 2. The symptoms of hemorrhoids include discomfort, pain, and bleeding, and can be caused by increased pressure in the veins of the rectum due to straining, pregnancy, chronic constipation, or prolonged sitting. To manage hemorrhoids, the following treatment options can be considered:
- Increase fiber intake to 25-30 grams daily through foods or supplements like psyllium (Metamucil) or methylcellulose (Citrucel)
- Drink 6-8 glasses of water daily to soften stool
- Avoid straining during bowel movements and limit sitting on the toilet
- Take warm sitz baths for 10-15 minutes, 2-3 times daily
- Use over-the-counter treatments like witch hazel pads (Tucks), hydrocortisone creams (Preparation H), or pramoxine wipes to reduce pain and swelling For persistent or severe hemorrhoids, a doctor may recommend prescription-strength creams, minimally invasive procedures like rubber band ligation, or surgery for large hemorrhoids, as indicated by the American Gastroenterological Association medical position statement 3. However, surgery should only be considered for a small minority of patients who have failed medical and nonoperative therapy, or have symptomatic third-degree, fourth-degree, or mixed internal and external hemorrhoids 3. It is essential to note that the most recent guidelines recommend non-operative management as the first-line therapy, and flavonoids may be administered to relieve symptoms, although the evidence is moderate 1. Additionally, topical muscle relaxants may be used for thrombosed or strangulated hemorrhoids, although the evidence is low-quality 1. Overall, the management of hemorrhoids should prioritize non-operative treatment and lifestyle changes to reduce symptoms and prevent recurrence.
From the Research
Symptoms of Hemorrhoids
- Internal hemorrhoids typically present with prolapse or painless rectal bleeding 4
- External hemorrhoids also bleed and can cause acute pain if thrombosed 4
- Bright red, painless rectal bleeding during defecation is the most common presentation 5
- Hemorrhoids can cause symptoms such as discomfort, bleeding, and prolapse 6
Treatment Options for Hemorrhoids
- Medical therapy should be initiated with stool softeners plus local therapy to relieve swelling and symptoms 4
- Nonsurgical treatment for nonthrombosed hemorrhoids includes increased fiber intake, sitz baths, and drugs 5
- Rubber band ligation is the treatment of choice for grades 1 and 2 hemorrhoids 4, 5, 6
- Rubber band ligation, excisional hemorrhoidectomy, or stapled hemorrhoidopexy can be performed in patients with grade 3 hemorrhoids 4
- Excisional hemorrhoidectomy or stapled hemorrhoidopexy is recommended for treatment of grade 4 hemorrhoids 4
- Thrombosed external hemorrhoids can be treated conservatively or excised 4, 5, 6
- Adequate dietary fiber supplement and TONE (specifying exact treatment goals: three minutes at defecation, once-a-day defecation frequency, no straining during passing motions, enough fiber) can help avoid surgery in most patients with advanced hemorrhoids 7
Surgical Treatment Options
- Rubber band ligation causes less postoperative pain and fewer complications than excisional hemorrhoidectomy and stapled hemorrhoidopexy, but has a higher recurrence rate 4
- Excisional hemorrhoidectomy leads to greater surgical success rates but also incurs more pain and a prolonged recovery than office-based procedures 6
- Closed hemorrhoidectomy with diathermic or ultrasonic cutting devices may decrease bleeding and pain 6
- Stapled hemorrhoidopexy elevates grade III or IV hemorrhoids to their normal anatomic position by removing a band of proximal mucosal tissue 6
- Hemorrhoidal artery ligation may be useful in grade II or III hemorrhoids because patients may experience less pain and recover more quickly 6